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Skip the Artificial Tears for Allergic Conjunctivits

We're in the heavy pollen season here in Texas (and I presume most of the US) and we have a lot of ocular allergy patients with a lot of itching. When I was a 3rd year student in optometry school I had a patient who had obvious signs and symptoms of allergic conjunctivitis. I reported this to my supervisor at the time and he said something like: "great! Now what are you going to do about it?" I suggested Rx'ing the #1 topical antihistamine at the time, Patanol. "WHOA WHOA WHOA!!!!", he incredulously replied. "YOU NEED TO START WITH ARTIFICIAL TEARS!!!!" Uh, really? "YES REALLY!!", he exclaimed, getting increasingly agitated with me. As an aside this guy was not a fan of mine nor I of his, so I think he might have been just looking for some way to bust on me, but I digress. He made me tell this poor lady to use artificial tears 4x/day for a week and come back for a progress evaluation. A week later the lady was back with eyelids obviously swollen from heavy eye-rubbing and complaints of continued "intense" itching. We Rx'd her Patanol like I wanted to do 7 days earlier and she never came back, I assume (and would like to think) b/c she was finally less itchy. Well today I just read an article about "pink eye" suggesting that the #1 line of defense for allergic conjunctivitis is artificial tears. WHY? I still do not understand this. At all. We now have some great OTC topical antihistamines like Alaway. If your eyes are ITCHY you need to just skip the artificial tears go straight to topical antihistamines. Artificial tears will not treat ocular allergy. I'm sorry but they won't. The theory on this is that the artificial tears can be soothing to the cornea/eye and can "wash away" the allergens from the tear film. I mean OK but that's a little conservative IMO. You know it's itchy. Use the drop that is clinically designed for, and proven to stop the itch! Why are we wasting our time and the patient's time by going UBER CONSERVATIVE and telling them to start with tears? I don't. If they're itchy and I think its allergic I start with topical antihistamines. I think "dry eye" often gets improperly diagnosed in this profession when people complain of ocular itch, and I think OD's are taught that artificial tears are kind of a "cure-all" (or cure-most) for all sorts of eye problems. Maybe this harkens to a time when OD's couldn't Rx anything? Regardless, I am a fan of not wasting the patient's time nor mine. I make my 1st suggested treatment be the thing that is the MOST LIKELY TO WORK, not necessarily the thing that is the most conservative. EDIT: after posting this on Twitter with the hashtag #ocularallergy I read EVEN MORE articles suggesting dry eye and blepharitis/demodex as the cause of ocular itching. I just don't know if I agree. I'm not saying it's impossible for those to cause ocular itch but I *AM* saying that all things being equal and the presenting symptom being ocular itch that my 1st choice and everyone's should probably be antihistamines, not artificial tears. OK obviously during the exam if they have waxy buildup around lashes or punctate keratitis etc etc that changes things but we're not talking about that. We're talking about using antihistamines when you suspect an allergy cause and not wasting time with more a conservative suggestion of trying artificial tears.

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Comments

Thanks for your great blog! A month ago, I was holding a piece of wood for my friend using a circular saw when a foreign object shot into my eye. I flushed the eye and used Visine, but after a week a dark red line and significant pain did not go away. My optometrist said the because I have pinguecula, the foreign object had caused the inflammatory red line around it. After a week of Pred Forte and now Tobradex, the pain and the dark red line have not diminished. I know the ping is permanent, but in a case like this will the iflammation (dark red line and pain) diminish with time? What would you suggest?